Rex did not ensure its flight crews received training in the differences between passenger and freight‑configured Saab 340 aircraft, prior to being scheduled to fly freight operations.
The Pel-Air and Rex Saab 340 flight crew operating manuals did not include reference to the location and operation of the cross-valve handle or smoke curtain.
Saab did not include the smoke curtain fitment in pre-flight documentation for the cargo‑configured Saab 340 aircraft to inform flight crew of this difference from the passenger‑configured version.
Australian states and territories that engage in Large Air Tanker (LAT) operations have developed their own separate standard operating procedures (SOPs) for LATs and aerial supervision assets. This can result in safety requirements being omitted or misunderstood by the different tasking agencies, such as a minimum drop height, resulting in inconsistencies in the development and application of LAT SOPs.
The Coulson Aviation crew resource management practice of limiting the pilot monitoring (PM) announcements to deviations outside the target retardant drop parameter tolerances increased the risk of the aircraft entering an unrecoverable state before the PM would alert the pilot flying.
ATSB comment
Coulson Aviation have not advised the ATSB of any safety action taken to address this safety issue and therefore the ATSB issues the following safety recommendation.
Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.
Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.
The Coulson Aviation practice of recalculating the target retardant drop airspeed after a partial drop reduced the post-drop stall speed and energy‑height safety margins.
Sydney Trains Security Control Centre Standard Operating Procedure contained conflicting instructions on incident response, which were not aligned with the Sydney Trains Network Incident Management Plan (NIMP).
Sydney Trains Security Control Centre Operator was not alerted to tampering of the cameras at Kembla Grange Station that monitored the West Dapto Road Level crossing.
Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway.
Poseidon Sea Pilots’ (PSP) safety management system for pilotage operations did not have procedures or processes to manage predictable risks associated with increased river flow or pilotage operations outside normal conditions. This, in part, resulted in PSP not considering risks due to the increased river flow properly and not taking an active role until after the breakaway.
Ampol’s assessment of risk to the ship and facility did not consider water speed in excess of the design and safety limits for the ship and berth mooring arrangements.
Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway.
Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.
Although Airservices Australia’s fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, it had limited effectiveness as supervisors were not identifying low workload as a fatigue hazard.
Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.
Fly Oz's asymmetric training procedure involved failing one engine using the mixture control without confirmation the engine was subsequently restarted, rather than reducing throttle to simulate zero thrust in accordance with the Beechcraft E55 Airplane Flight Manual. This increased the risk of undetected asymmetric operation during descent and landing and the associated loss of control.
The risk assessments conducted by Southern Shorthaul Railroad (SSR) for shunting and banking operations did not include consultation consisting of effective and meaningful engagement with all relevant stakeholders. This increased the potential that risks could be missed during the risk assessment process.
Southern Shorthaul Railroad's (SSR's) emergency response procedures did not include requirements for banking locomotive operations.
